HRT
I am 48 years old but I had my kids early and ended up with a group of friends mostly 5-10 years older than me. It’s been years now that the hot flashes, sleep deprivation and mood changes of the menopausal transition have been a topic of conversation in my social circles. Despite my encouragement, very few of my friends have opted for treatment with Menopausal Hormone Therapy (MHT).
Back in the old days we called MHT “Hormone Replacement Therapy”, but this is a misnomer. Our treatments in menopause are typically a quarter, or a half of the level of estrogen your body made naturally in your 40s. So we’re not replacing your hormones, we’re using a dose as low as possible to treat your symptoms.
We all know about MHT, and most of us probably know that it’s the best way to reduce hot flashes and improve sleep for menopausal people. So why aren’t all my hot and bothered friends lining up to get it? Unfortunately, the misinformation epidemic has sunk its dirty yellow teeth into hormone therapy.
Back in the 1900s, MHT was commonly prescribed. The best data available were from the Nurses' Health Study, which showed that nurses using MHT had lower mortality rates and overall better health, including significantly lower risks of heart disease and stroke. So doctors designed a trial called the Women's Health Initiative (WHI) to see if treating women ages 50-79 with synthetic hormones (the most cost-effective available at the time) improved their cardiovascular risk.
Scientists were surprised by the results; in older women (average age 65) they found an INCREASE in the risk of heart disease, stroke, and breast cancer. Within 3 months, prescriptions for HRT dropped by 32% and many women now perceive MHT as dangerous. So why would your doctor recommend a dangerous therapy? The answer is, they wouldn’t. The science has evolved, and we have a more detailed understanding of who will benefit from MHT and who should avoid it.
Important updates:
MHT decreases mortality by 40% when started within 10 years of the menopausal transition
What we now understand is that hormone therapy prevents the atherosclerotic changes in blood vessels that caused heart attacks and strokes in older women in the WHI. If you start hormones years after menopause, the damage is already done and hormones will make things worse rather than better. If you start hormones within a few years of the menopausal transition, MHT actually DECREASES heart attacks and strokes.
Bio-identical hormones (estrogen patch or gel, and Prometrium or the Mirena IUD) prevent increased blood clots (VTE), stroke, and cholesterol changes
The WHI trial used synthetic hormones that are known to cause these problems, so the type of MHT we’re using in most patients now is much safer than the medications in the original study.
Breast cancer risk does not change with MHT treatment for less than 5 years
Breast cancer risk is slightly increased after more than 5 years of estrogen and progesterone, but LESS THAN IF YOU DRINK A GLASS OF WINE PER DAY. That’s right, moderate alcohol intake has a higher risk of breast cancer than MHT.
Vaginal estrogen is NOT considered MHT because the dose is so low. One year of vaginal estrogen therapy is equivalent to the amount of estrogen in about one oral menopause pill.
In the UK vaginal estrogen is sold over-the-counter, so you can bring a suitcase home and give it to all your friends. Vaginal estrogen decreases mortality in older women with a history of recurrent bladder infections, and does not increase mortality in breast cancer survivors.
Conclusions:
If you are under age 60 and have hot flashes that make your life misery and keep you from sleeping, you should consider MHT.
If you are under age 60 and have osteoporosis or a strong family history of fractures, you should consider MHT.
If you have brain fog, MHT isn’t likely to help. It’s similar to pregnancy brain and will pass after a few years.
If you have painful intercourse, vaginal dryness, and/or overactive bladder, you should consider a 3-month trial of vaginal estrogen.